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February 19, 2013 Issue

Clinical Practice Points

Acupuncture in Patients With Seasonal Allergic Rhinitis. A Randomized Trial

This randomized trial found that acupuncture resulted in improved measures of quality of life and antihistamine use as compared with each sham acupuncture and "rescue" use of antihistamine.

Use this study to:

  • Review conventional therapy for allergic rhinitis (use In The Clinic: Allergic Rhinitis for an eminently practical review, and to download teaching slides and MKSAP questions to launch discussions).
  • Discuss residents’ comfort level with discussing and recommending complementary and alternative medicine (CAM). Why did this trial have sham and no intervention comparison groups? Should we be more hesitant to embrace CAM than "new" allopathic treatments? An accompanying editorial can help guide the discussion (Acupuncture Research in the Era of Comparative Effectiveness Research).

Optimal Timing of Coronary Invasive Strategy in Non–ST-Segment Elevation Acute Coronary Syndromes. A Systematic Review and Meta-analysis

This study concluded that available evidence was insufficient to draw firm conclusions regarding an advantage of early versus delayed invasive treatment for NSTEMI in mortality, MI, or major bleeding.

Use this study to:

  • Discuss the acute evaluation of a patient with an acute coronary syndrome.
  • Discuss your institution’s approach to management of patients with NSTEMI. Should it change on the basis of this review?
  • Start your teaching session with a question from MKSAP (we’ve provided one below).

Definition of a Positive Test Result in Computed Tomography Screening for Lung Cancer. A Cohort Study

This study from a large prospective cohort of patients screened for lung cancer with CT estimates how many false-positive results might have been avoided and cancer diagnoses delayed using varying definitions for a “positive” nodule.

Use this study to:

  • Discuss what an acceptable threshold might be between avoiding false-positive results and missed diagnoses in a lung cancer screening program. What are the dangers of a false-positive result?
  • Review the importance of tumor stage in determining the chance of curative surgery for lung adenocarcinoma.

Humanism and Professionalism

Preventing Trauma Surgeons From Becoming Family Doctors

In this On Being a Doctor, a trauma surgeon describes how the cycle of violence has led to frequent interactions with the same family as sequential loved ones are hurt and killed by violence.

Use this article to:


ACP Journal Club

Peruse this month’s ACP Journal Club’s concise, authoritative, single-page reviews of recently published articles from over 130 clinical journals that have been assessed for quality and clinical relevance. Choose one to help lead a lunch-time journal club. Or, have a “Rapid-Fire Round-Robin Residents Journal Club” and assign several residents to each present the key messages and remaining unanswered questions from a study featured in an ACP Journal Club summary. Your residents also can sign up for personalized ACPJC alerts according to their interests at http://journalwise.acponline.org/.


mksap16

A 73-year-old man is evaluated in the hospital following a non-ST-elevation myocardial infarction. He has type 2 diabetes mellitus and dyslipidemia. Medications are aspirin, simvastatin, metoprolol, lisinopril, clopidogrel, and metformin. He is nearing discharge.

On physical examination, temperature is normal. Blood pressure is 110/80 mm Hg and pulse rate is 52/min. Heart sounds are normal, lung fields are clear, and there is no peripheral edema.

Laboratory studies:

Total cholesterol 112 mg/dL (2.90 mmol/L)
HDL cholesterol 42 mg/dL (1.09 mmol/L)
LDL cholesterol 55 mg/dL (1.42 mmol/L)
Triglycerides 73 mg/dL (0.82 mmol/L)
Creatinine 1.2 mg/dL (106 µmol/L)
Potassium 4.2 meq/L (4.2 mmol/L)
Fasting plasma glucose 110 mg/dL (6.1 mmol/L)

Electrocardiogram demonstrates sinus rhythm and nonspecific ST-T wave changes. Echocardiogram demonstrates an ejection fraction of 30% and no evidence of left ventricular thrombus.

Which of the following is the most appropriate adjustment to his discharge medications?

A. Discontinue clopidogrel
B. Increase metoprolol dose
C. Start eplerenone
D. Start warfarin

Answer: C. Start eplerenone

Key Point: Agents that block the renin-angiotensin-aldosterone system are particularly beneficial in high-risk patients with an acute coronary syndrome, such those with left ventricular ejection fraction of 40% or below and either heart failure symptoms or diabetes mellitus.

Educational Objective: Choose appropriate medical management for a patient with diabetes mellitus and coronary artery disease.

This patient with diabetes mellitus and an acute coronary syndrome would benefit from starting an aldosterone antagonist such as eplerenone. The 2007 American College of Cardiology/American Heart Association guidelines recommend the administration of an aldosterone antagonist to all patients following a non-ST-elevation myocardial infarction (NSTEMI) who are receiving an ACE inhibitor, have a left ventricular ejection fraction of 40% or below, and have either heart failure symptoms or diabetes mellitus. Contraindications to the use of an aldosterone antagonist in this setting include chronic kidney disease and hyperkalemia. Agents that block the renin-angiotensin-aldosterone system are particularly beneficial in high-risk patients, and the presence of diabetes places this patient in that category.

The EPHESUS trial randomized patients presenting with an acute coronary syndrome, left ventricular systolic dysfunction (ejection fraction ≤ 40%), and either heart failure or diabetes to the aldosterone antagonist eplerenone or placebo in addition to optimal medical therapy. There was a 15% relative risk reduction in all-cause mortality and a 13% relative risk reduction in cardiovascular mortality/cardiovascular complications in the eplerenone group compared with the placebo group. The aldosterone antagonist should be initiated before hospital discharge because a mortality benefit can be seen within the first 30 days of adding the medication.

Clopidogrel or another thienopyridine should be added to background aspirin therapy in all patients following a NSTEMI regardless of their TIMI risk score unless there is an elevated risk of bleeding, such as recent gastrointestinal bleeding or newly diagnosed anemia. Guidelines recommend the continuation of clopidogrel for at least 1 year following a NSTEMI.

Increasing the β-blocker is incorrect because this patient's resting heart rate is sufficiently low, and increasing the dose may result in symptomatic bradycardia.

Current guidelines recommend the use of warfarin therapy following NSTEMI only in those patients who are at high risk for embolization, such as those with atrial fibrillation and left ventricular thrombus. This patient has none of these indications.

Bibliography
Pitt B, Remme W, Zannad F, et al; Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 2003;348(14):1309-1321. PMID: 12668699

This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Erin Ney, MD, FACP Assistant Residency Program Director, Department of Internal Medicine, Thomas Jefferson University.

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